Detection of Bronchiolitis Obliterans Syndrome Following Pediatric Hematopoietic Stem Cell Transplantation. An Official American Thoracic Society Clinical Practice Guideline.

BACKGROUND: Many children undergo allogeneic Hematopoietic Stem Cell Transplantation (HSCT) for the treatment of malignant and non-malignant conditions. Unfortunately, pulmonary complications occur frequently post-HSCT, with bronchiolitis obliterans syndrome (BOS) being the most common non-infectious pulmonary complication. Current international guidelines contain conflicting recommendations regarding post-HSCT surveillance for BOS, and a recent National Institutes of Health workshop highlighted the need for a standardized approach to post-HSCT monitoring. As such, this guideline provides an evidence-based approach to detection of post-HSCT BOS in children. METHODS: A multinational, multidisciplinary panel of experts identified six questions regarding surveillance for, and evaluation of post-HSCT BOS in children. Systematic review of the literature was undertaken to answer each question. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of recommendations. RESULTS: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations addressing the role of screening pulmonary function testing and diagnostic tests in children with suspected post-HSCT BOS were made. Following a Delphi process, new diagnostic criteria for pediatric post-HSCT BOS were also proposed. CONCLUSIONS: This document provides an evidence-based approach to detection of post-HSCT BOS in children, while also highlighting considerations for implementation of each recommendation. Further, the document describes important areas for future research.

Improving HIV Case Finding Through Index Testing: Findings from Health Facilities in 12 Districts of South Africa, October 2019-September 2021.

To assess the importance of index testing in HIV case finding, we analyzed quarterly data from October 2019 to September 2021 from 371 facilities in 12 districts in South Africa. Index testing accounted for 2.6% of all HIV tests (index and non-index) (n = 163,633), but 17.8% of all HIV-positive results, with an HIV-positivity 4-times higher than non-index testing modalities (4.1%). Despite twice as many adult females ≥ 15 years accepting index testing (n = 206,715) compared to adult males ≥ 15 years (n = 102,180), females identified fewer contacts (n = 91,123) than males (n = 113,939). Slightly more than half (51.2%) of all contacts elicited were tested (n = 163,633/319,680), while 19.7% (n = 62,978) of elicited contacts were previously diagnosed as HIV-positive and not eligible for further testing. These findings indicate index testing can be effective in increasing HIV diagnoses in South Africa. Further operational research is needed to address gaps identified in the index testing cascade, including elicitation and testing of contacts.

Descriptive study: the novel "full spectrum people-with-opioid-use-disorder care model".

BACKGROUND: People with Opioid Use Disorder (PWOUD) represent an underserved and marginalized population for whom treatment gaps exist. Low-barrier programs like mobile care units and street outreach programs have yielded increased access to buprenorphine and social services, however, OUD pertinent co-occurring behavioral health and medical conditions are frequently left unaddressed. A novel, tailored, comprehensive care delivery model may reduce disparities and improve access to care across a range of pathologies in this historically difficult to reach population and enhance efforts to provide universal treatment access in a harm reduction setting. METHODS: Descriptive data were collected and analyzed regarding patient demographics, retention in treatment and services rendered at a new, wrap-around, low-barrier buprenorphine clinic established at an existing harm reduction site in New Mexico between August 1, 2020, and August 31, 2021. RESULTS: 203 people used any service at the newly implemented program, 137 of whom specifically obtained medical and/or behavioral health care services including prescriptions for buprenorphine at least once from the physician onsite. Thirty-seven unique medical and psychiatric conditions were treated, representing a total of 565 separate encounters. The most common service utilized was buprenorphine treatment for opioid use disorder (81%), followed by treatment for post-traumatic stress disorder (62%), anxiety (44.5%) and depression (40.9%). Retention in buprenorphine treatment was 31.2% at 6 months. CONCLUSIONS: An innovative, multidisciplinary, buprenorphine-centric care model, which targets a wide range of OUD pertinent pathologies while employing a harm reduction approach, can enhance utilization of these services among an underserved PWOUD population in a manner which moves our health system toward universal OUD treatment access thereby potentially reducing overdose and existing disparities.

Mini All-Suture Anchors for Repairing the Central Slip of the Extensor Tendon at the Proximal Interphalangeal Joint: A Biomechanical Investigation.

PURPOSE: This study evaluated 1.0-mm mini suture anchors for repairing the central slip of the extensor mechanism at the proximal interphalangeal joint. Studies have reported a requirement for central slip fixation to withstand 15 N during postoperative rehabilitation exercises and 59 N during forceful contraction. METHODS: Index and middle fingers from 10 matched pairs of cadaveric hands were prepared with 1.0-mm mini suture anchors with 2-0 sutures or threaded with 2-0 sutures through a bone tunnel (BTP). In total, 10 index fingers from unmatched hands were prepared with suture anchors and fixed to the extensor tendons to evaluate the tendon/suture interface response. Each distal phalanx was secured to a servohydraulic testing machine, and ramped tensile loads were applied to suture or tendon until failure. RESULTS: All anchors for the all-suture bone tests failed because of pullout from the bone (Mean failure force = 52.5+/-17.3 N). Three anchors from the tendon-suture pull out test failed by pullout from the bone and seven failed at the tendon/suture interface (Mean failure force = 49.0+/-10.1 N). CONCLUSIONS: The 1.0-mm mini suture anchor provides enough strength for early short-arc motion, but it may not be adequate for forceful contraction in the early postoperative rehabilitation stage. CLINICAL RELEVANCE: The site of fixation, the type of anchor, and the type of suture used are key factors to consider for early range of motion, after surgery.

A Biomechanical Analysis of the H-Taping Method Used by Rock Climbers as Prophylactic or Stabilizing Fixation of Partial A2 Pulley Tears.

PURPOSE: Rock climbing can lead to upper-extremity injuries, such as A2 pulley ruptures, leading to the bowstringing of the flexor tendons. Climbing finger positions are specific and can put undue stress on the pulley systems. This causes severe hand dysfunction and is a difficult problem to treat, and prevention is important. Using a cadaveric, experimental model, we evaluated the effectiveness of the H-taping method, commonly used by rock climbers, to prevent and treat A2 pulley tears. METHODS: Using fourteen matched pairs of fresh-frozen cadaveric hands with forearms, four experiments were conducted with 56 paired comparisons evaluating the failure force, fingertip force, and mode of failure (112 total tests). Comparisons were as follows: index fingers- intact versus 50% distal A2 pulley tears without H-taping (control); ring fingers- intact versus H-taping as a prophylactic for A2 pulley tears; little fingers- 50% distal A2 pulley tears with H-tape versus without tape; and middle fingers- H-taping as a prophylactic versus H-taping as a stabilizing treatment of torn pulleys. RESULTS: The mean index finger failure force was significantly higher in intact vs torn A2 pulleys (control). Failure force for intact H-taped fingers was significantly higher than torn H-taped fingers, but no other finger comparisons for failure force were significant. There were no significant findings in comparison of mean fingertip force values in any of the experiments. CONCLUSIONS: We found that H-taping is not effective as prophylaxis against A2 pulley ruptures or as a stabilizing treatment method for partially ruptured pulleys. CLINICAL RELEVANCE: While H-taping has not been recommended as prophylaxis for preventing A2 pulley ruptures, the climbing community has embraced this technique as a preventative measure. The present study provides biomechanical evidence against H-taping for this purpose. Furthermore, it does not appear to aid in increasing fingertip force after injury.

Pediatric HIV Case Identification Across 22 PEPFAR-Supported Countries During the COVID-19 Pandemic, October 2019-September 2020.

During 2020, an estimated 150,000 persons aged 0-14 years acquired HIV globally (1). Case identification is the first step to ensure children living with HIV are linked to life-saving treatment, achieve viral suppression, and live long, healthy lives. Successful interventions to optimize pediatric HIV testing during the COVID-19 pandemic are needed to sustain progress toward achieving Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets.* Changes in HIV testing and diagnoses among persons aged 1-14 years (children) were assessed in 22 U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries during October 1, 2019-September 30, 2020. This period corresponds to the two fiscal quarters before the COVID-19 pandemic (i.e., Q1 and Q2) and the two quarters after the pandemic began (i.e., Q3 and Q4). Testing was disaggregated by age group, testing strategy, and fiscal year quarter. During October 2019-September 2020, PEPFAR supported 4,312,343 HIV tests and identified 74,658 children living with HIV (CLHIV). The number of HIV tests performed was similar during Q1 and Q2, decreased 40.1% from Q2 to Q3, and increased 19.7% from Q3 to Q4. The number of HIV cases identified among children aged 1-14 years (cases identified) increased 7.4% from Q1 to Q2, decreased 29.4% from Q2 to Q3, and increased 3.3% from Q3 to Q4. Although testing in outpatient departments decreased 21% from Q1 to Q4, testing from other strategies increased during the same period, including mobile testing by 38%, facility-based index testing (offering an HIV test to partners and biological children of persons living with HIV) by 8%, and testing children with signs or symptoms of malnutrition within health facilities by 7%. In addition, most tests (61.3%) and cases identified (60.9%) were among children aged 5-14 years (school-aged children), highlighting the need to continue offering HIV testing to older children. These findings provide important information on the most effective strategies for identifying CLHIV during the COVID-19 pandemic. HIV testing programs should continue to use programmatic, surveillance, and financial data at both national and subnational levels to determine the optimal mix of testing strategies to minimize disruptions in pediatric case identification during the COVID-19 pandemic.

Adapting strategies for effective and efficient pediatric HIV case finding in low prevalence countries: risk screening tool for testing children presenting at high-risk entry points in Ethiopia.

BACKGROUND: Implementing effective and efficient case-finding strategies is crucial to increasing pediatric antiretroviral therapy coverage. In Ethiopia, universal HIV testing is conducted for children presenting at high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC); however, low positivity rates observed at inpatient, malnutrition and OVC entry points warrant re-assessing current case-finding strategies. The aim of this study is to develop HIV risk screening tool applicable for testing children presenting at inpatient, malnutrition and OVC entry points in low-HIV prevalence settings. METHODS: The study was conducted from May 2017-March 2018 at 29 public health facilities in Amhara and Addis Ababa regions of Ethiopia. All children 2-14 years presenting to five high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC) were enrolled after consent. Data were collected from registers, medical records, and caregiver interviews. Screening tools were constructed using predictors of HIV positivity as screening items by applying both logistic regression and an unweighted method. Sensitivity, specificity and number needed to test (NNT) to identify one new child living with HIV (CLHIV) were estimated for each tool. RESULTS: The screening tools had similar sensitivity of 95%. However, the specificities of tools produced by logistic regression methods (61.4 and 65.6%) which are practically applicable were higher than those achieved by the unweighted method (53.6). Applying these tools could result in 58‒63% reduction in the NNT compared to universal testing approach while maintaining the overall number of CLHIV identified. CONCLUSION: The screening tools developed using logistic regression method could significantly improve HIV testing efficiency among children presenting to malnutrition, inpatient, and OVC entry points in Ethiopia while maintaining case identification. These tools are simplified to practically implement and can potentially be validated for use at various entry points. HIV programs in low-prevalence countries can also further investigate and optimize these tools in their settings.

The development of task sharing policy and guidelines in Kenya.

BACKGROUND: The global critical shortage of health workers prevents expansion of healthcare services and universal health coverage. Like most countries in sub-Saharan Africa, Kenya's healthcare workforce density of 13.8 health workers per 10,000 population falls below the World Health Organization (WHO) recommendation of at least 44.5 doctors, nurses, and midwives per 10,000 population. In response to the health worker shortage, the WHO recommends task sharing, a strategy that can increase access to quality health services. To improve the utilization of human and financial health resources in Kenya for HIV and other essential health services, the Kenya Ministry of Health (MOH) in collaboration with various institutions developed national task sharing policy and guidelines (TSP). To advance task sharing, this article describes the process of developing, adopting, and implementing the Kenya TSP. CASE PRESENTATION: The development and approval of Kenya's TSP occurred from February 2015 to May 2017. The U.S. Centers for Disease Control and Prevention (CDC) allocated funding to Emory University through the United States President's Emergency Plan for AIDS Relief (PEPFAR) Advancing Children's Treatment initiative. After obtaining support from leadership in Kenya's MOH and health professional institutions, the TSP team conducted a desk review of policies, guidelines, scopes of practice, task analyses, grey literature, and peer-reviewed research. Subsequently, a Policy Advisory Committee was established to guide the process and worked collaboratively to form technical working groups that arrived at consensus and drafted the policy. The collaborative, multidisciplinary process led to the identification of gaps in service delivery resulting from health workforce shortages. This facilitated the development of the Kenya TSP, which provides a general orientation of task sharing in Kenya. The guidelines list priority tasks for sharing by various cadres as informed by evidence, such as HIV testing and counseling tasks. The TSP documents were disseminated to all county healthcare facilities in Kenya, yet implementation was stopped by order of the judiciary in 2019 after a legal challenge from an association of medical laboratorians. CONCLUSIONS: Task sharing may increase access to healthcare services in resource-limited settings. To advance task sharing, TSP and clinical practice could be harmonized, and necessary adjustments made to other policies that regulate practice (e.g., scopes of practice). Revisions to pre-service training curricula could be conducted to ensure health professionals have the requisite competencies to perform shared tasks. Monitoring and evaluation can help ensure that task sharing is implemented appropriately to ensure quality outcomes.

Geographic and temporal diversity in dental morphology reflects a history of admixture, isolation, and drift in African Americans.

OBJECTIVES: While genetic studies have documented variation in admixture proportions in contemporary African Americans across the US, relatively little is known about the socio-historical roots of this variation. Our goal in this study is to use dental morphology to explore the socio-historical correlates of admixture, localized gene flow, and drift in African Americans. METHODS: Our data are ordinally-graded dental morphological traits scored in 196 Africans, 335 Europeans and European Americans, 291 pre-Spanish-contact Native Americans, and 722 African Americans. The African American data derived from contemporary and historic samples. We eliminated from analysis individuals and traits with greater than 20% missing data. We summarized the major axes of trait variation using principal component analysis (PCA), estimated biological distance, constructed multidimensional scaling (MDS) plots of the distances, and measured the correlation between geographic and biological distance. RESULTS: In the PCA, African American groups clustered between Africans and Europeans on PC 1, reflecting admixture between the groups. PC 2 separated African American samples, possibly reflecting movement, isolation, and drift. MDS analyses confirmed the existence of sizable biological distances between African American samples, especially between contemporary and past African American samples. We found no relationship between biological and geographic distances. DISCUSSION: We demonstrate that admixture and drift can be inferred from multi-variable analyses of patterns of dental morphology in admixed populations. Localized gene flow has not affected patterns of trait variation in African Americans, but long-range movement, isolation, and drift have. We connect patterns of dental trait variation to efforts to flee oppression during the Great Migration, and the repeal of anti-miscegenation laws.

Informativeness of dental morphology in ancestry estimation in African Americans.

OBJECTIVES: Our objective is to assess the informativeness of dental morphology in estimating biogeographic ancestry in African Americans. MATERIALS AND METHODS: The data are 62 dental morphological traits scored as nondichotomized and dichotomized in 797 individuals, 992,601 SNPs from 271 individuals, and 645 STRs from 177 individuals. Each dataset consists of Africans, Europeans, and African Americans. For each dataset, we summed Fisher Information (FI), then used STRUCTURE to estimate ancestry. RESULTS: Total FI was highest for SNPs, followed by STRs, nondichotomized dental traits, and dichotomized dental traits. For both genetic datasets, Africans and Europeans fell into two distinctive clusters with low 90% credible regions for individual ancestry estimates. In African Americans, membership in the African cluster was 76.4% and 80.4% for SNPs and STRs, respectively. For the dental data, all Africans and Europeans had appreciable membership in both clusters and comparatively high 90% credible regions for individual ancestry estimates. Nonetheless, African Americans had consistently higher membership in the same cluster in which Africans had high membership. African American membership in this cluster was significantly higher for the nondichotomized form than for the dichotomized. DISCUSSION AND CONCLUSIONS: FI potentially provides a useful gauge of the effectiveness of dental and genetic data for ancestry estimation. The comparatively high FI of nondichotomized dental traits suggests data in this form may be better suited for studies of admixture than dichotomized data. Because of high error in individual ancestry estimates, dental morphological data may be unable to distinguish differences in ancestry among individuals within admixed populations.

Tests of fit of historically-informed models of African American Admixture.

OBJECTIVES: African American populations in the U.S. formed primarily by mating between Africans and Europeans over the last 500 years. To date, studies of admixture have focused on either a one-time admixture event or continuous input into the African American population from Europeans only. Our goal is to gain a better understanding of the admixture process by examining models that take into account (a) assortative mating by ancestry in the African American population, (b) continuous input from both Europeans and Africans, and (c) historically informed variation in the rate of African migration over time. MATERIALS AND METHODS: We used a model-based clustering method to generate distributions of African ancestry in three samples comprised of 147 African Americans from two published sources. We used a log-likelihood method to examine the fit of four models to these distributions and used a log-likelihood ratio test to compare the relative fit of each model. RESULTS: The mean ancestry estimates for our datasets of 77% African/23% European to 83% African/17% European ancestry are consistent with previous studies. We find admixture models that incorporate continuous gene flow from Europeans fit significantly better than one-time event models, and that a model involving continuous gene flow from Africans and Europeans fits better than one with continuous gene flow from Europeans only for two samples. Importantly, models that involve continuous input from Africans necessitate a higher level of gene flow from Europeans than previously reported. DISCUSSION: We demonstrate that models that take into account information about the rate of African migration over the past 500 years fit observed patterns of African ancestry better than alternative models. Our approach will enrich our understanding of the admixture process in extant and past populations.

Evaluation of the impact of the ARC program on national nursing and midwifery regulations, leadership, and organizational capacity in East, Central, and Southern Africa.

BACKGROUND: The African Health Professions Regulatory Collaborative (ARC) was launched in 2011 to support countries in East, Central, and Southern Africa to safely and sustainably expand HIV service delivery by nurses and midwives. While the World Health Organization recommended nurse initiated and managed antiretroviral therapy, many countries in this region had not updated their national regulations to ensure nurses and midwives were authorized and trained to provide essential HIV services. For four years, ARC awarded annual grants, convened regional meetings, and provided technical assistance to country teams of nursing and midwifery leaders to improve national regulations related to safe HIV service delivery. We examined the impact of the program on national regulations and the leadership and organizational capacity of country teams. METHODS: Data was collected to quantify the level of participation in ARC by each country (number of grants received, number of regional meetings attended, and amount of technical assistance received). The level of participation was analyzed according to two primary outcome measures: 1) changes in national regulations and 2) improvements in leadership and organizational capacity of country teams. Changes in national regulations were defined as advancement of one "stage" on a capability maturity model; nursing and midwifery leadership and organizational capacity was measured by a group survey at the end of the program. RESULTS: Seventeen countries participated in ARC between 2012 and 2016. Thirty-three grants were awarded; the majority addressed continuing professional development (20; 61%) and scopes of practice (6; 18%). Fourteen countries (representing approximately two-thirds of grants) progressed at least one stage on the capability maturity model. There were significant increases in all five domains of leadership and organizational capacity (p < 0.01). The number of grants (Kendall's tau = 0.56, p = 0.02), duration of technical assistance (Kendall's tau = 0.50, p = 0.03), and number of learning sessions attended (Kendall's tau = 0.46, p = 0.04) were significantly associated with improvements in in-country collaboration between nursing and midwifery organizations. CONCLUSIONS: The ARC program improved national nursing regulations in participating countries and increased reported leadership, organizational capacity, and collaboration among national nursing and midwifery organizations. These changes help ensure national policies and professional regulations underpin nurse initiated and managed treatment for people living with HIV.

Cross-sectional description of nursing and midwifery pre-service education accreditation in east, central, and southern Africa in 2013.

BACKGROUND: In 2013, the World Health Organization issued guidelines, Transforming and Scaling Up Health Professional Education and Training, to improve the quality and relevance of health professional pre-service education. Central to these guidelines was establishing and strengthening education accreditation systems. To establish what current accreditation systems were for nursing and midwifery education and highlight areas for strengthening these systems, a study was undertaken to document the pre-service accreditation policies, approaches, and practices in 16 African countries relative to the 2013 WHO guidelines. METHODS: This study utilized a cross-sectional group survey with a standardized questionnaire administered to a convenience sample of approximately 70 nursing and midwifery leaders from 16 countries in east, central, and southern Africa. Each national delegation completed one survey together, representing the responses for their country. RESULTS: Almost all countries in this study (15; 94%) mandated pre-service nursing education accreditation However, there was wide variation in who was responsible for accrediting programs. The percent of active programs accredited decreased by program level from 80% for doctorate programs to 62% for masters nursing to 50% for degree nursing to 35% for diploma nursing programs. The majority of countries indicated that accreditation processes were transparent (i.e., included stakeholder engagement (81%), self-assessment (100%), evaluation feedback (94%), and public disclosure (63%)) and that the processes were evaluated on a routine basis (69%). Over half of the countries (nine; 56%) reported limited financial resources as a barrier to increasing accreditation activities, and seven countries (44%) noted limited materials and technical expertise. CONCLUSION: In line with the 2013 WHO guidelines, there was a strong legal mandate for nursing education accreditation as compared to the global average of 50%. Accreditation levels were low in the programs that produce the majority of the nurses in this region and were higher in public programs than non-public programs. WHO guidelines for transparency and routine review were met more so than standards-based and independent accreditation processes. The new global strategy, Workforce 2030, has renewed the focus on accreditation and provides an opportunity to strengthen pre-service accreditation and ensure the production of a qualified and relevant nursing workforce.

MarginProbe© reduces the rate of re-excision following breast conserving surgery for breast cancer.

PURPOSE: A positive margin status after breast conserving surgery (BCS) is one of the strongest predictors for local recurrence of intraductal (DCIS) and invasive carcinoma. As much as 20-50 % of patients with BCS need to undergo a second operation to receive free margins. In this study we tested the clinical performance of MarginProbe© (Dune Medical Devices, Paoli, PA, USA), a device for the intraoperative evaluation of surgical margins. METHODS: A prospective clinical study was performed: The device was utilized in BCS of 150 patients treated at a single facility from November 2012 to June 2013. The re-excision rate was compared to the re-excision rate of a historical group of 172 patients treated with BCS at the same hospital without the application of the device. We analyzed whether the results of MarginProbe© are affected by the morphology, grading, size of the tumor, breast density, age, BMI or the use of marker-wires. RESULTS: The application of MarginProbe© resulted in an overall decreased re-excision rate of 14.6 %. In the subgroup of DCIS the re-excision rate was reduced from 61.7 to 23.1 %. In the subgroup of invasive lobular carcinomas the re-excision rate decreased from 37.0 to 19.0 %. MarginProbe© results were not affected by grading, tumor size, breast density, age, BMI or marker-wire application. CONCLUSION: MarginProbe© detects positive margins in invasive carcinoma, DCIS as well as in invasive lobular carcinoma. The device decreases the re-excision rate after BCS significantly. It does not interfere with any of the factors we examined.

Informing the scale-up of Kenya's nursing workforce: a mixed methods study of factors affecting pre-service training capacity and production.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

The impact of recreational cannabinoid legalization on utilization in a pregnant population.

Background: Marijuana potency and utilization both continue to increase across the United States. While the overall prevalence of cannabinoid utilization during pregnancy has been surveyed in various studies, the direct impact of changing governmental policies on pregnancy use is less characterized. Thus, we aimed to investigate how the legalization of recreational cannabinoid products impacted use during pregnancy in the state of New Mexico. Methods: Participants who had a live birth during two study epochs were included: pre-legalization (Epoch 1: 1 January 2019-31 March 2021) and post-legalization (Epoch 2: 1 November 2021-30 November 2022). Participants were further divided into case group [prenatal cannabinoid exposure (PCE)] vs. control (no PCE), with cases being identified by documented self-report or a positive laboratory toxicology test for cannabinoid use during pregnancy. Results: A total of 1,191 maternal/infant dyads were included in Epoch 1, and 378 maternal/infant dyads were included in Epoch 2. In Epoch 1, 788 dyads were controls with 403 cases, while Epoch 2 had 292 controls and 86 cases. Interestingly there was a significant decrease in self-report or positive laboratory toxicology tests in Epoch 2 compared to Epoch 1. Infants born following PCE in both Epoch groups were more commonly born via Cesarean section, had significantly smaller birth weight, length, and head circumference as well as significantly lower Apgar scores at 1 and 5 min. Conclusion: The finding of decreased reported cannabinoid use in the post-legalization group is contradictory to previous studies which have shown increased rates of cannabinoid use after legalization. This could be due to multiple factors including changes in screening practices, the COVID-19 pandemic, and lack of commercialization of THC products. Additional studies are needed to further characterize how changing governmental policies impacts utilization during pregnancy.

The Use of Knotless Suture Tape Construct vs Screw Fixation for Lisfranc Injuries: A Cadaveric Biomechanical Study.

BACKGROUND: Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw. METHODS: Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. RESULTS: Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. CONCLUSION: Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state. CLINICAL RELEVANCE: In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

Nursing and midwifery regulatory reform in east, central, and southern Africa: a survey of key stakeholders.

BACKGROUND: In sub-Saharan Africa, nurses and midwives provide expanded HIV services previously seen as the sole purview of physicians. Delegation of these functions often occurs informally by shifting or sharing of tasks and responsibilities. Normalizing these arrangements through regulatory and educational reform is crucial for the attainment of global health goals and the protection of practitioners and those whom they serve. Enacting appropriate changes in both regulation and education requires engagement of national regulatory bodies, but also key stakeholders such as government chief nursing officers (CNO), professional associations, and educators. The purpose of this research is to describe the perspectives and engagement of these stakeholders in advancing critical regulatory and educational reform in east, central, and southern Africa (ECSA). METHODS: We surveyed individuals from these three stakeholder groups with regard to task shifting and the challenges related to practice and education regulation reform. The survey used a convenience sample of nursing and midwifery leaders from countries in ECSA who convened on 28 February 2011, for a meeting of the African Health Profession Regulatory Collaborative. RESULTS: A total of 32 stakeholders from 13 ECSA countries participated in the survey. The majority (72%) reported task shifting is practiced in their countries; however only 57% reported their national regulations had been revised to incorporate additional professional roles and responsibilities. Stakeholders also reported different roles and levels of involvement with regard to nursing and midwifery regulation. The most frequently cited challenge impacting nursing and midwifery regulatory reform was the absence of capacity and resources needed to implement change. DISCUSSION: While guidelines on task shifting and recommendations on transforming health professional education exist, this study provides new evidence that countries in the ECSA region face obstacles to adapting their practice and education regulations accordingly. Stakeholders such as CNOs, nursing associations, and academicians have varied and complementary roles with regard to reforming professional practice and education regulation. CONCLUSION: This study provides information for effectively engaging leaders in regulatory reform by clarifying their roles, responsibilities, and activities regarding regulation overall as well as their specific perspectives on task shifting and pre-service reform.

Appendicitis in an Appendicostomy.

A 25-year-old man presented with right lower quadrant abdominal wall erythema, a punctum of purulence, and localized pain at the site of a previous appendicostomy. Cross-sectional imaging revealed appendicitis at his previous appendicostomy with a fecalith near the skin. He was managed with appendectomy. The surgical approach mimicked a loop ileostomy reversal by circumferentially dissecting the tissue around the appendicostomy to the level of the fascia and then dividing the appendix at the base of the cecum through a small two-centimeter incision. Appendicitis in a previous appendicostomy is uncommon and has only been described in three previous case reports (two adults and one child) and was surgically approached through a low-midline laparotomy. Our case is unique as it is an uncommon presentation of a common disease managed with a minimally invasive approach not previously described.

Evaluation of quality of life in breast cancer patients who underwent breast-conserving surgery or mastectomy using real-world data.

BACKGROUND: Due to advances in the fight against breast cancer, aesthetic aspects and the prevention of breast deformities are playing an important role in surgical procedures. Currently the main form of breast cancer surgery is breast-conserving surgery (BCS), and even if mastectomy (MAS) is required, oncoplastic surgery and reconstruction options can improve outcomes, including health-related quality of life (QoL) of cancer patients. The purpose of this study was to assess whether surgery options induce different outcomes in self-reported QoL in guide-line treated breast cancer patients of the Network Oncology (NO). METHODS: This prospective Real-World-Data (RWD) study was conducted using data from the NO-clinical registry. QoL was assessed by evaluation of the European Organization of Research and Treatment Health-Related Quality of Life Core Questionnaire scale (EORTC QLQ-C30). Association factors between type of surgery options, without or with immediate breast reconstructions the EORTC QLQ-C30-scales at baseline after surgery, 6, 12, and 24 months later were analyzed with adjusted multivariate regression analysis, considering age, cancer stage, and treatment regimens, using software R. RESULTS: A total of 623 primary breast cancer patients (all tumor stages, median age 58 (ICR: 50-68) diagnosed and guide-line treated between 2013 and 2021), 524 BCS and 99 MAS, 24 of whom received immediate breast reconstruction (MBR), were eligible for analyses. Compared with BCS patients, MBR patients self-reported considerably lower global health, physical and social functioning, and higher burden of pain and financial difficulties at baseline. In later follow-up surveys, functional scales increased and symptoms decreased in all patients, and the differences between MAS and BCS equalized. Longitudinal analyses after 24 months were obtained from 258 patients and revealed that compared to 224 BCS, the 34 MAS patients reported increased social functioning (p = 0.04). CONCLUSIONS: At 24 months after MAS, breast cancer patients' QoL improved compared with BCS, although impairments in QoL were reported immediately after MAS. A growing expertise in surgical procedures as well as supportive care is critical to optimizing patients' well-being. These findings may be considered when counseling breast cancer patients pre- and post-surgery. TRIAL REGISTRATION NUMBER: DRKS00013335 on 27/11/2017 retrospectively registered.